European Journal of Neurology 2012, 19: 537–543 doi:10.1111/j.1468-1331.2011.03562.

CME ARTICLE

The clinical spectrum of intracerebral hematoma, hemorrhagic

infarct, non-hemorrhagic infarct, and non-lesional venous stroke in
patients with cerebral sinus–venous thrombosis
E. Kumrala, F. Polata, C. Uzunköprüa, C. Çallıb and Ö. Kitişb
a _
Stroke Unit, Neurology Department, Ege University, School of Medicine, Izmir; and bRadiology Department, Ege University, School of
_
Medicine, Izmir, Turkey

Keywords:
cerebral venous thrombo-
sis, intracerebral hemor-
rhage, sinus thrombosis,
venous hemorrhagic
infarct
Received 14 July 2011
Accepted 31 August 2011
Background and purpose: The clinical spectrum of different neuroradiological fea-
tures of cerebral sinus–venous thrombosis (CSVT) varies considerably. We sought the
relationship between different neuroradiological aspects and clinical presentations in
these patients.
Methods: The diagnosis of cerebral sinus–venous thrombosis has been confirmed by
conventional angiography, MRI combined with MR venography following established
diagnostic criteria. We analyzed clinical data, symptoms and signs, imaging findings,
location and extent of the thrombus, and parenchymal lesions, retrospectively.
Results: There were 220 consecutive patients with cerebral sinus–venous thrombosis;
98 (45%) had non-lesional sinus–venous thrombosis (NL CSVT), 51 (23%) had non-
hemorrhagic infarct (NHI), 45 (20%) had hemorrhagic infarct (HI), and 26 (12%) had
intracerebral hemorrhage (ICH). In patients with hemorrhagic lesion (HI+ICH),
advanced age, headache (99%), behavioral disturbances (55%), consciousness dis-
turbances (35%), seizures (41%), and language deficits (42%) were significantly higher
than the other patients (NL+NHI) (P < 0.001). High blood pressure at admission,
puerperium, sigmoid and straight sinus thrombosis, multiple sinus and vein involve-
ment were more frequent in patients with hemorrhagic lesion than those with non-
hemorrhagic lesion. Patients with hemorrhagic lesion were more dependent or died
(32%) than the other patients (12%) (P < 0.001), and most of the patients with NL
and NHI had no disability compared with the other patients at the 3 month of follow-
up (96% and 65%; P < 0.001).
Conclusion: Headache, convulsion, behavioral disorder, seizures, and speech disor-
ders were the most frequent clinical symptoms of patients with hemorrhagic CSVT.
Specific risk factors, including pregnancy/puerberium, early and extended thrombosis
of large sinus, and presence of high blood pressure at admission, are associated with
hemorrhagic lesion and unfavorable outcome.

edema with mass effect. Because of increased intracra-

Introduction
Cerebral sinus–vein thrombosis (CSVT) can be diag-
nosed by the sensitive neuroimaging techniques in the
early period of venous stroke. Following sinus–vein
thrombus, venous congestion and hemorrhagic trans-
formation within the brain secondary to decreased
venous outflow may develop and leads to cerebral
Correspondence: E. Kumral, Stroke Unit, Department of Neurology,
Faculty of Medicine, Ege University, Bornova, Izmir 35100, Turkey
(tel.: +90 532 2165213; fax: +90 232 4634626; e-mail: emre.kumral
@ege.edu.tr).
This is a Continuing Medical Education article, and can be found with
corresponding questions on the Internet at http://www.efns.org/EFNS
Continuing-Medical-Education-online.301.0.html. Certificates for
correctly answering the questions will be issued by the EFNS.
nial pressure and involvement of vascular supply,
ischemia and hemorrhagic lesions may develop [1,2]. In
sinus–venous stroke, all current literature indicates that
sinus–vein thrombosis without a lesion on computerized
tomography (CT) or MRI, venous non-hemorrhagic
infarct (NHI), hemorrhagic infarct (HI), and intrace-
rebral hematoma represent continuum of parenchymal
lesions reflecting successive grades of intravenous pres-
sure and CSVT severity [3–9]. It is apparent that each
step of sinus–vein thrombosis may represent a different
step by virtue of lesion enlargement, clinical presenta-
tion, outcome, and treatment strategies.
This study was undertaken to analyze the relation-
ship between neuroradiological findings and clinical

 2011 The Author(s)

European Journal of Neurology  2011 EFNS 537
538 E. Kumral et al.
features in patients with CSVT in the early phase of
sinus–venous stroke.
Methods
We studied 220 consecutive patients with diagnosis of
CSVT in our Stroke Registry, who were admitted to
our Stroke Unit between January 1998 and May 2010,
retrospectively [10]. The diagnosis of CSVT was based
on clinical suspicion and imaging confirmation, and
regarding to the clinical categories published recently
[11]. The CSVT was divided into four subgroups
according to neuroradiological findings as following; (i)
intracerebral hematoma (ICH) was considered if the
patient had a confluent hemorrhagic lesion >1 cm on
CT and MRI; (ii) venous HI was deemed if there is
hypodensity with or without focal area of hyperdensity
corresponding to small hemorrhage on CT, and MRI
fast fluid-attenuated inversion recovery (FLAIR)
sequence demonstrating heterogenous area of hyperin-
tensity and/or hypointensity, diffusion-weighted imag-
ing (DWI) displaying predominant hyperintense area,
and apparent diffusion coefficient (ADC) map showing
mixed areas of decreased and/or slightly increased ADC
values; (iii) NHI was defined if there is an ischemic
lesion without additional lesion corresponding to
hemorrhage on initial and following repeated CT and
MRI; (iv) non-lesional CSVT (NL) was described if the
radiological examination revealed neither an ischemic
nor hemorrhagic lesion on CT and MRI, but conven-
tional angiography or MR venography showed an
occlusion of sinus–vein system.
All patients underwent neuroimaging examinations,
including CT and MRI in the first 72 h of admission,
and reviewed for lesion sites, presence of venous
infarction, and parenchymal hemorrhage. MR imaging
sequences were performed with a 1.5-T MR unit
(Magnetom Vision; Siemens Medical systems, Erlan-
gen, Germany) including T1- and T-2 weighted
sequences, FLAIR imaging sequence, and DWI se-
quences with ADC calculations. MRA and magnetic
resonance venography (three-dimensional time-of-flight
sequences) were obtained during the same imaging
session. Two senior neuroradiologists were blinded to
the clinical information. Interobserver agreement for
the radiological assessment according to criteria men-
tioned previously was higher between neuroradiologists
(j = 0.78).
We recorded demographic and clinical data, lesions
at admission on computed tomographic and MRI
scans, (left, right or bilateral hemisphere, single or
multiple), location of thrombosis, consciousness alter-
ations, clinical symptoms, seizures, and visual loss, any
associated illness and medication or condition that
European Journal of Neurology  2011 EFNS European Journal of Neurology
might predispose to thrombosis, including pregnancy
and puerperium, oral contraceptives, malignancies,
systemic inflammatory disease, hematologic diseases,
coagulation disorders, infectious diseases, bowel dis-
ease, cardiac disease. Patients without a history of
hypertension but with high blood pressure on admis-
sion (>140/85 mmHg) was recorded. Of 220 patients,
174 (79%) were treated by anticoagulants including
subcutaneous non-fractionated heparin (heparin bolus
of 3000 U followed by continuous intravenous infusion
to achieve an activated partial thromboplastin time
twice the pre-treatment value) and low-molecular
weight heparin (nadroparin dosed on the basis of body
weight –180 anti-factor Xa units per kilogram daily in
two divided doses) within the first 24 h of admission.
We did not start anticoagulation in 20% of patients
presenting either a major contraindication for antico-
agulation, such as major hemorrhage or clinical
regression without parenchymal damage, because of the
risks and benefits of anticoagulation. The presence of
clinical worsening during hospitalization was recorded,
but there was no systematic imaging data on the
occurrence of new hemorrhagic lesions after anticoag-
ulant initiation. All subjects were evaluated clinically on
15th day, second and third months to determine the
patients functional final outcome. Ethic committee of
the University Hospital approved the concept and
design of the study (EUTF-2010).
Statistical analysis
Descriptive statistics are reported as mean and range.
Outcome analysis included short-term mortality and
functional outcome assessment at 15th day, 2nd and 3th
month following discharge by the modified Rankin
scale (mRS): mRS(0–2), no or minor disability; mRS
(3–6), dependent and death; mRS (6), death. One-way
2
ANOVA or Pearson v test when appropriate were used
to assess relationships between variables. The post hoc
analysis was made by Bonferroni and Tukeys tests and
pairwise multiple comparisons to assess which means
differ. A second analysis with Pearson v2 test and 95%
CI was made by separating patients into two groups;
patients without hemorrhagic lesion (NL +NHI) and
those with hemorrhagic infarct (HI+ICH), to estimate
risk factors in the way cause of hemorrhage. Logistic
regression analysis was conducted to select the best
working correlation structure for the unstandardized
and standardized coefficients (B) and 95% CI between
two groups. In the regression analysis, different models
were constructed by probability-of-F-to-enter £0.05 to
select the best working correlation between groups by
entering variables such as age, sex, high blood pressure,
pregnacy/puerberium, sigmoid and straight sinus
 2011 The Author(s)
 The clinical/neuroradiological spectrum of cerebral sinus–vein thrombosis 539

thrombosis, multiple sinus and sinus–veins involve-
ment. All data were analyzed with SPSS 17.0 (SPSS
Inc., Chicago, IL, USA) statistical software.
Results
Among 220 patients, 152 (69%) patients were female,
and the mean age was 44 ± 7 years old (range, 18–
75 years). Of these, 121 (55%) patients had only sinus
thrombosis, 77 (35%) had concomitant sinus and vein
thrombosis, and 22 (10%) had only vein thrombosis.
Ninety-eight patients (45%) had no lesion on CT/MRI,
51 (23%) had NHI, 45 (21%) had HI, and 26 (12%)
presented ICH.
High blood pressure at admission was found more
frequently in patients with HI and ICH compared those
with NHI and NL (22% and 15% vs. 4% each;
P = 0.002). Headache, sensorial deficits, seizures, dys-
arthria and aphasia, and behavioral deficits (anxiety,
depression) were significantly higher in patients with
hemorrhagic lesion (Table 1). Consciousness loss was
significantly higher in patients with HI and ICH com-
pared those with NL CSVT and NHI (20% and 27%
vs. 0% and 2%; P = 0.001). Sigmoid sinus involve-
ment was significantly more frequent in patients with
NHI and HI (53% and 64%; P = 0.001). The fre-
quency of multiple sinus involvement was more higher
in patients with NHI, HI, and ICH than those with NL
CSVT (73% and 62% each vs. 21%; P = 0.001). The
involvement of straight sinus was significantly higher in
patients with ICH and NHI (31% and 29%;
P = 0.001). (Table 2). Post hoc range and pairwise

Table 1 Demographic features and clinical findings in patients with cerebral sinus–vein thrombosis regarding to non-lesional venous stroke, non-
hemorrhagic infarct, hemorrhagic infact, and intracerebral hemorrhage

Clinical presentation NL (n = 98) NHI (n = 51) HI (n = 45) ICH (n = 26) Pa

Age ± SD (range) 42 ± 9 (18–61) 43 ± 10 (25–70) 46 ± 10 (26–62) 54 ± 11 (35–75)b 0.001

Male/female 35/63 17/34 6/39b 10/16 0.04
High blood pressure 4 (4) 2 (4) 10 (22)b 4 (15) 0.002
Diabetes mellitus 10 (10) 4 (8) 5 (11) 1 (4) 0.7
Hypercholesterolemia 13 (13) 6 (12) 8 (18) 2 (8) 0.7
Hyperhomocystinemia 11 (11) 7 (14) 6 (13) 7 (27) 0.2
Clinical findings
Headache 84 (86) 48 (94) 45 (100) 25 (96) 0.02
Mental status
Normal 92 (94) 43 (84) 31 (69) 15 (58) 0.001
Confusion/drowsiness 6 (6) 7 (14) 5 (11) 4 (15)
Coma 0 1 (2) 9 (20) 7 (27)b
Behavioral findings 10 (10) 13 (26) 24 (53) 15 (58)b 0.001
Papilledema 9 (9) 8 (16) 9 (20) 10 (39)b 0.04
Diplopia 9 (8) 13 (25) 6 (13) 9 (35)b 0.02
Cranial nerve palsies 11 (11) 10 (20) 10 (22) 11 (46)b 0.04
Motor deficits 2 (2) 15 (29) 15 (33) 12 (35) 0.001
Sensorial deficits 11 (11) 8 (16) 16 (36) 9 (35) 0.001
Ataxia 6 (6) 15 (29) 12 (27) 8 (31) 0.001
Visual blurring 18 (18) 5 (10) 6 (13) 7 (27) 0.2
Seizures 17 (17) 11 (22) 23 (51)b 11 (42) 0.001
Focal 10 (10) 6 (12) 12 (27) 9 (35)
Generalized 5 (5) 4 (8) 9 (20) 1 (4)
Status epilepticus 2 (2) 1 (2) 2 (4) 1 (4)
Speech disorders
Dysarthria 9 (9) 4 (8) 20 (44)b 10 (39) 0.001
Aphasia 11 (11) 5 (10) 10 (22) 9 (35)b 0.01
Outcomec
No or minor disability (mRS 0–2) 94 (96)b 33 (65) 23 (51) 8 (31) 0.001
Mild and severe disability (mRS 3–5) 2 (4) 17 (33) 14 (31) 13 (50)b 0.001
Dependent and death (mRS 3–6) 2 (2) 16 (31) 19 (42)b 4 (15) 0.001
Death 0 0 8 (18)b 2 (8) 0.001

NL, non-lesional sinus–venous thrombosis; NHI, non-hemorrhagic infarct; HI, hemorrhagic infarct; ICH, intracerebral hemorrhage; mRS
modified Rankin score.
Values in parenthese are percentage of column.
a
Pearson v2 test; df:3.
b
Significantly different group mean at Post hoc multiple comparison tests.
c
At the 3 month of follow-up.

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European Journal of Neurology  2011 EFNS European Journal of Neurology
540 E. Kumral et al.

Table 2 Etiology and sinus–venous involvement regarding to non-lesional venous stroke, non-hemorrhagic infarct, hemorrhagic infact, and
intracerebral hemorrhage

Clinical presentation NL (n = 98) NHI (n = 51) HI (n = 45) ICH (n = 26) P

Etiology
Pregnancy/puerperium 7 (7) 5 (10) 15 (33)a 7 (27) 0.001b
Oral contraceptives 11 (11) 4 (8) 7 (16) 6 (23) 0.2
SLE 12 (12) 4 (8) 6 (13) 3 (12) 0.8
APA 8 (8) 2 (4) 4 (9) 2 (8) 0.8
Hematologic disorders
Protein-C deficiency 6 (6) 3 (6) 3 (7) 0 0.6
Protein-S deficiency 9 (9) 1 (2) 5 (11) 2 (8) 0.3
Factor V mutation 9 (3) 2 (2) 1 (2) 1 (4) 0.3
Antithrombin III deficiency 3 (3) 0 4 (9) 1 (4) 0.1
Prothrombin II mutation 3 (1) 1 (2) 1 (2) 1 (4) 0.9
Polycythemia 0 4 (8) 3 (7) 0 0.02
MTHFR 677T mutation 3 (3) 3 (6) 5 (11) 0 0.1
Dehydratation 0 4 (8) 1 (2) 2 (8) 0.03
Behçets disease 9 (9) 5 (10) 1 (2) 3 (12) 0.4
Intracranial mass 5 (5) 1 (2) 1 (2) 0 0.5
Meningioma 3 (3) 1 (2) 1 (2) 0
Astrositoma 2 (2) 0 0 0
Sinus involved (n = 121)c
Superior sagittal sinus 40 (41) 21 (41) 23 (51) 13 (50) 0.6
Inferior sagittal sinus 12 (12) 14 (28) 8 (18) 5 (19) 0.1
Transverse sinus 48 (49) 28 (55) 23 (51) 14 (54) 0.9
Sigmoid sinus 27 (27) 27 (53) 29 (64)a 11 (42) 0.001
Juguler sinus 10 (10) 7 (14) 6 (13) 1 (4) 0.6
Straight sinus 5 (5) 15 (29) 9 (20) 8 (31)a 0.001
Cavernous sinus 9 (9) 2 (4) 1 (2) 2 (7) 0.4
Multiple sinus involvement 21 (21) 37 (73) 28 (62) 16 (62) 0.001
Veins involved (n = 22)c 15 (15) 1 (2) 5 (11) 1 (4) 0.05
Cortical venous system 8 (8) 0 2 (4) 1 (4)
Deep venous system 7 (2) 1 (2) 3 (7) 0
Combined vein+sinus (n = 77)c 12 (12) 25 (49) 21 (47) 19 (73)a 0.001

HI, hemorrhagic infarct; ICH, intracerebral hemorrhage; NHI, non-hemorrhagic infarct.

Values in parenthese are percentage of column.
a
significantly different group mean at Post hoc multiple comparison tests.
b
Pearson v2 test; df:3.
c
Column number totals may exceed the total number of patients in some groups because some patients involved more than one sinus or vein.

multiple comparisons tests determined that female
gender was significantly higher in patients with HI, and
the mean differences in the other clinical and risk fac-
tors were because of the means of patients with HI and
ICH.
Parietal lobe involvement was present in 39% (20/51)
of patients with NHI, in 44% of those with HI, and in
58% of those with ICH. Frontal lobe was affected in
23% of patients with NHI, in 31% of those with HI,
and in 27% of those with ICH. Temporo-occipital lobes
were involved in 35% of patients with NHI, in 13% of
those with HI, and in 11% of those with ICH.
Comparison of patients with hemorrhagic lesion and
without showed that age, female gender, high pressure
on admission, pregnancy/puerperium, sigmoid sinus
involvement, multiple sinus thrombosis, and concomi-
tant sinus–veins thrombosis were significantly higher in
patients with hemorrhagic lesions (Table 3). Logistic
regression analysis of risk factors showed a strong
correlation between age, sex, high blood pressure at
admission, sinus–vein thrombosis, multiple sinus
involvement, and hemorrhagic lesions (Table 4).
Most of the patients with NL CSVT and NHI pre-
sented complete and partial recovery (96% and 65%),
while patients with HI and ICH had more severe dis-
ability or death (mRS 3–6) (42% and 35%; P = 0.001)
at the 3 month of follow-up. Eight of 174 (4.6%)
patients who were treated by anticoagulants and 2 of 46
(4.3%) patients without anticoagulant treatment died
(OR = 1.1, 95% CI 0.2–5.2; P = 0.7). Among 71
patients with hemorrhagic lesions, 14% (8/58) of pa-
tients, who were treated by anticoagulants and 15% (2/
13) of patients who were treated by conservative
treatment, died (OR = 0.9, 95% CI 0.2–4.7; P = 0.6).

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European Journal of Neurology  2011 EFNS European Journal of Neurology
 The clinical/neuroradiological spectrum of cerebral sinus–vein thrombosis 541

Table 3 Risk and vascular factors in patients with hemorrhagic lesion vs. those without hemorrhagic lesion

Patients with Patients without

hemorrhagic lesion hemorrhagic lesion OR (95% CI) P

Age 42.2 ± 9 48.6 ± 10 0.001a

Gender (M/F) 16/55 52/97 1.9 (0.9–3.5) 0.06
High blood pressure 6 (30) 14 (70) 0.2 (0.06–0.47) 0.001
Pregnancy/puerperium 12 (35) 22 (65) 0.2 (0.09–0.4) 0.001
Sigmoid sinus involvemet 54 (57) 40 (43) 0.4 (0.3–0.8) 0.005
Straight sinus involvement 20 (54) 17 (46) 0.5 (0.2–1.0) 0.051
Multiple sinus involvement 32 (40) 48 (60) 0.1 (0.07–0.3) 0.001
Sinus–vein thrombosis 32 (42) 45 (58) 6.3 (3.4–11.8) 0.001

Values in parenthese are percentage of rows.

a
ANOVA test.

Table 4 Logistic regression analysis coefficients and 95% CI in the

was no systematic control of imaging during follow-up.
model regarding to risk factors in patients with hemorrhagic lesion vs. In our study, the diagnosis and radiological examina-
those with non-hemorrhagic lesion tion was made in the 3 day of admission, while as
reported in International Study on Cerebral Vein and
Coefficients B Exp (B) 95% CI P
Dural Sinus Thrombosis (ISCVT) trial symptom onset
Model variables could be subacute in half of the patients, and median
Female sex 0.9 2.54 0.99–6.5 0.05 delay from onset to diagnosis was 1 week [9].
Age 0.7 1.07 1.0–1.1 0.001
Headache, seizures, speech deficits, and conscious-
High blood pressure )1.9 0.15 0.04–0.59 0.006
Sinus–vein thrombosis 1.5 4.6 2.2–9.8 0.001 ness and behavioral disturbances were the most
Multiple sinus involvement )1.7 0.18 0.08–0.4 0.001 frequent symptoms in patients with hemorrhagic le-
Pregnancy/puerperium )1.3 0.27 0.1 to )0.75 0.01 sions. Post hoc analysis showed that consciousness
Straight sinus )0.2 0.86 0.3–2.2 0.8 disturbances, behavioral deficits, papilledema, diplopia,
Sigmoid sinus 0.1 1.1 0.5–2.5 0.8
and cranial nerve involvement were associated signifi-
cantly in patients with ICH. Severe consciousness dis-
turbance at onset was correalated significantly with
poor outcome. Early partial epileptic seizures were
Discussion
present especially in patients with hemorrhagic lesions,
In our study, several important clinical and risk factor while generalized seizures were seen mostly in patients
features distinguished in patients with different neuro- with HI, which could be due to irritative phenomenon
radiological findings. Among risk factors, the age, high of hemorrhage. In ISCVT trial, risk factors for early
blood pressure on admission, pregnacy/puerberium, seizures were hemorrhagic lesion on admission CT/
and multiple sinus–veins involvement were found to be MRI, and paresis [5].
associated with hemorrhagic lesion on imaging. The In our study, the frequency of pregnancy/puerperium
higher risk of hemorrhagic lesion was present in cases of was higher in patients with HI and ICH, which can be
thrombosis located at the sigmoid sinus, straight sinus, explained by several mechanisms such as prothrom-
and in those extented thromboses involving simulta- botic changes, volume depletion and trauma, increasing
neously sinus and veins may give rise to insufficient maternal age, cesarean delivery, and presence of
drainage by other sinus. The high blood pressure was hypertension. Among hereditary prothrombotic condi-
observed frequently in patients with hemorrhagic tions, none of them had an effect on the development of
lesion, which is probably secondary to the intracerebral different neuroradiological features. Previous large
bleeding that raised intracranial pressure. Early CT/ series did not demonstrate significant relationship
MRI combination showed that HI was present in one- between thrombophilia, either genetic or acquired and
fifth of the patients, and one-tenth had ICH mostly in sinus–venous infarct or hemorrhage [5,7,13,14].
the parietal and frontal lobes. A hemorrhagic lesion was In our series, the rate of death was not different in
present on CT/MRI at the 3th days of admission in patients who were treated either by anticoagulants or
almost one-third of the patients, and this could be due by conservative treatment, while patients with hemor-
to an acute increase in venous and capillary system rhagic lesion who were treated by anticoagulants had
pressure and venous wall damage [7,12]. Our method- more frequent but statistically unsignificant mortality
ological limitation was the lack of information about rate than those without a hemorrhagic lesion at the 3rd
the duration of symptoms before admission, and there month of follow-up. The assumption that anticoagula-

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European Journal of Neurology  2011 EFNS European Journal of Neurology
542 E. Kumral et al.
tion had an adverse effect on the clinical outcome in
patients with hemorrhagic brain lesions cannot be
derived from the presented data. Moreover, hemor-
rhage itself is an independent predictor for a poor
clinical outcome. Limited data from randomized con-
trolled clinical trials in combination with observational
data on outcomes and bleeding complications of anti-
coagulation support a role for anticoagulation in the
treatment of CSVT [15–21]. It is logical that in the
special situation of a patient with a recent hemorrhagic
lesion, the clinician must balance the risks and benefits
of anticoagulation, depending on the clinical situation.
In the clinical routine practice, low-intensity anticoag-
ulation may be considered if possible in favor of no
anticoagulation until such time as it might be safe to use
full-intensity anticoagulation.
The outcome of patients with NL, NHI was good,
and more than two-thirds was discharged with complete
or partial recovery, while half of the patients with HI
was independent at the 3rd month of follow-up.
Approximately, two-thirds of the patients having ICH
were dependent, which could be a predictor of an
unfavorable outcome in these patients. The ISCVT trial
[9,22] reported that 3.4% of patients died within
30 days from symptom onset, and risk factors were
depressed consciousness, altered mental status, tran-
stentorial herniation secondary to a large hemorrhagic
lesion, and diffuse brain edema, supporting the findings
found in our series. Another recent study showed that
patients with non-hemorrhagic lesion had a better
prognosis in the acute phase and at the end of follow-up
than those with hemorrhagic lesion [22].
In conclusion, risk factors including involvement of
large and multiple sinus, pregnancy/puerperium, and
advanced age may predispose patients to sinus–venous
hemorrhagic stroke and unfavorable outcome. Patients
admitted for CSVT having hemorrhagic lesion should
be considered as being at risk and deserve additional
close monitoring. New treatment options, besides
anticoagulation, should be considered cautiously
because it is necessary to identify predictors of hemor-
rhagic lesions to avoid from the death and poor
outcome.
Disclosure of conflict of interest
The authors declare no financial or other conflict of
interests.
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European Journal of Neurology  2011 EFNS European Journal of Neurology